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Physical Therapists and Contracts

Our family's traditional stocking stuffer extravaganza took place last week.  For those of you unfamiliar, this event is highlighted by driving for 10 minutes to find the last parking space at the mall, entering the mall and hearing Christmas music, negotiating the dollar limit for the stuffed stocking while eating the grease at the food court, determining the time limit to accomplish the feat, and of course, exchanging last minute wishes between our kids.  This tradition is for our kids and they are solely responsible for each others' stockings.

As our daughter and I embarked on our mission, we came upon this sign.  It made me pause and think.  This sign could be the future of physical therapists.  Really... John and Larry have shared (multiple times throughout the years) the contracts coming down the pipes.  If physical therapist business owners continue down the path of making life easy for referral sources by participating with all third party arrangements and accepting contracts that pay poorly because something is better than nothing, the one change that just might have to happen is reflected in this sign. 

How many physical therapists do you know that love their career so much they they would be willing to be paid $24.99/month? 

~Selena

The Rise of "Integrative Medicine"

Many of us in the world of scientific medicine (which naturally includes the readers of EIM!) have been alarmed at the steady rise in popularity of the so-called "Integrative Medicine" movement. The following consists of my personal opinion and commentary on this topic.
For those unfamiliar with the term "Integrative Medicine", here's the WebMD entry: IM

The Wikipedia entry is a little more telling: Integrative Medicine. As of this writing, it redirects you to the "Alternative Medicine" entry. Interesting.

So what gives? I think IM is theoretically an attempt to combine some popular alternative methods into standard science/evidence-based care. This might be due to the desire of the patient to have some of these therapies, or a desire of the practitioner to be seen as "open-minded". In practice however, I think IM is the combination of dubious (and often ridiculous) treatments with standard medical care. Therefore I think it typically results in the addition of nothing significant at the risk of conveying some dangerous ideas regarding the nature of medicine and the role of the practitioner in healthcare. For example, the responsibility of the practitioner to be an "honest broker" about the patient's healthcare options and the science and evidence underpinning those options.

There have recently been some articles in the mainstream media about the IM movement, both on MSNBC and on Fox News.

As usual, both Quackwatch and the Science-Based Medicine blog are excellent resources on this topic.
Quackwatch on IM
SBM on IM

I think we've all seen some examples of integrative medicine in physical therapy clinics. Perhaps you've seen a colleague provide a treatment of questionable value in addition to treatments you thought made sense. I know I have.
I don't think much of IM myself, and I make sure I have a good answer when patients ask me why I'm not using this or that alternative method. I feel that's an important part of my responsibility as a healthcare practitioner.

I close with a quote from Dr John Farley PhD, found at the Quackwatch link. I think it encapsulates the issue perfectly.

"Integrative" medicine is purportedly combining alternative and mainstream approaches to medicine. The claim is that integrative medicine provides the best of both approaches. This may sound reasonable, but actually it is not. Suppose that the "integrative" approach were to spread beyond medicine, and were to be more broadly adopted by other disciplines in the sciences. The biologists would "integrate" creationism with Darwinian evolution, while the chemists would integrate alchemy into modern scientific chemistry. The geologists would integrate the belief that the world is only 6000 years old (and flat) with modern dating of rocks. Physicists would integrate perpetual motion machines with the conservation of energy and the laws of thermodynamics. And the astronomers would integrate astrology and astronomy. Of course, this is ridiculous. It's not a good idea to integrate nonsense with valid scientic knowledge."

What is the proper role of IM in physical therapy, and what are its boundaries? What do you think?

-Jason Silvernail DPT

Health 2.0 and Lack of Control of Information

The world seems so much smaller.  It seems as though everyone has an opinion. 

Is it true the more "followers" one has the more valid the person being "followed?"  Has this become like a status symbol of expertise or something?  Has this become the status symbol of a leader?

More and more consumers are turning to the internet for medical information.  This can be good... but at the same time, I question the validity and the reliability of the information they receive.  I recently watched a presentation that suggested that consumers tend to place the same level of value of what others in their same situation believe as they do their physicians.  I have mixed feelings about some of the Health 2.0 networking that occurs.  I think it can be great from a support group kind of perspective; I'm a bit leary about consumers telling each other "what worked" for them. 

It seems as though everyone has a blog these days.  Everyone has a right to an opinion.  What if that opinion is wrong?  What if the information being shared is wrong?  How much impact does a blogger have on consumers?  Who "follows" the blogger?  How strong is the alliance between the blogger and the "followers?"

I've decided that if I see something that really, really seems to be inaccurate about physical therapists, I WILL step in and comment. 

My Google Reader fed me a recent blog post:  The Ugly Truth About Physical Therapists.  I couldn't bear to let the post go without an appropriate comment.  Poor Jamie still didn't understand and a follow up comment was definitely required in Personal Trainer vs Physical Therapist - the "deathmatch."

I don't know about the rest of you, but it is irritating to have a lack of control of what consumers can learn about physical therapists.  Who knew that personal trainers, according to Jamie, are becoming more and more similar to physical therapists?  What a bad, bad seed to plant for consumers....

Anyways... be an advocate for physical therapists.  Who knows what we do or have to offer better than ourselves?  Help consumers understand their options. 

~Selena

Does the APTA PT-PAC Need Some Funds?

Moving Forward is moving.

President Obama will be trying to solve difficult problems.

What do you do when the economy is horrible, membership might be down and you need money for lobbying?

Just like Jersey Girl, a little bit of ingenuity and grasping of an opportunity is required.

An opportunity has been extended by Intuit for a small business grant.  Follow along for just a bit - I always have a point, it's just going to take me a bit to get there.

 As of right now, there are 4 physical therapists "sharing their story:" 

King Rehab Services in Toms River, NJ

Joints in Motion Physical Therapy in Flower Mound, TX

Ryndak Physical Therapy in Bloomingdale, IL

AND, yours truly, at Red Cedar Physical Therapy, LLC in Williamston, MI 

Now, here's the scoop.  In order for any competitor to be in the competition, so to speak, the stories need to be rated.  Every one of the above stories have had people viewing, but no one voting.  Not a single person has rated any of the stories written by physical therapists.  Stories are rated as inspiring, useful or funny.  Finalists are chosen by a combination of user ratings (40%), quality (40%) and creativity (20%).

The story I wrote really isn't "my story." My goal was to be an advocate for physical therapists on one hand and to have the story represent what physical therapists who own physical therapy businesses face every day as best as possible.  By writing the story, a whole different audience, so to speak, will learn a bit about physical therapists.  

Here's the twist...  if enough reviewers rate my story between now and March 23 at enough of a volume that the story is in the finalist category at any level, I will pledge 1/2 of the financial reward to the APTA PT-PAC.  Michigan's economy isn't the greatest right now, but this small business grant appears to be a perfect opportunity for me/us to use to help support the APTA PT-PAC.  Feel free to share AND rate - I'll support the APTA PT-PAC because of YOUR support!

~Selena

Asking, Listening and Identifying Patterns

 Westby G. Fisher, MD, FACC had me thinking the last couple of days.  If he wasn't being sarcastic and he really did have a light bulb experience from this recent finding on electrocardiograms, I had to contemplate why.

Why is there hesitation and lack of certainty to identify some physical complaints using the non-technical, simple approach of asking relevant questions and really listening to a patient's response?  Why is there lack of confidence and comfort in taking a good history and performing an examination based on the information obtained from the history?  How much should it cost and how much further testing should be required to call a duck a duck?  Why is it that confirmation of history and examination generally always occurs via further, expensive diagnostic testing?  (Is it really needed?)  Then on the flip side from a patient perspective - and, I hear this from patients all the time, "I don't want surgery."  So, if a patient doesn't want surgery (whether the person is a candidate or not for surgery), why any further diagnostic testing? 

Think of how often we know that in the musculoskeletal world, diagnostic imaging can shed light on some abnormality but the finding really doesn't correlate with the subjective or clinical presentation.  If the imaging isn't going to provide some new insight to help guide the treatment, what's the point?  What exactly changes when a physician tells a patient, "you have really bad degenerative changes."  Wait, let's not go down that path, because that leads to a whole different discussion.

Is there evidence available that can can provide a higher level of value to a good history and examination?  Back in 1992, Sackett wrote a nice editorial discussing the barriers (which I believe are still true today) for valuing a good history and examination.  At the beginning of that editorial though, he provided 2 statistics to think about:  He cited Crombie - 88% of the time a diagnosis was established after a history and short exam; he also cited Sandler - 73% of the time patients were accurately diagnosed after an examination.  Sackett did a fabulous job in this article in bringing home the value of evidence-based decisions by comparing the evidence for a few simple questions with advanced diagnostic testing.  He tied everything together by using a patient example. 

As health care and health care costs are continually analyzed, physical therapists have more value than we may have initially considered.  We really haven't been extremely dependent on diagnostic testing to assist in clinical decision-making.  Research that focuses on highlighting relevant factors in the history taking and clusters of examination findings (and providing the sensitivities, specificities and likelihood ratios) will strengthen both the value of our diagnosis and our confidence in calling a duck a duck.  The other beauty of our role is that society does not expect a physical therapist to order diagnostic testing, which means we can be seen as a viable alternative that breaks the expectation cycle of having every diagnostic test under the sun performed.

Can physical therapists be seen as an integral solution to reducing health care costs?  Are we ready to be a part of the solution?

photo by monkeyc.net via Flickr

Selena

Stop the Merry Go Round- Direct Access Please!

The Problem: Timely access and provider choice for patients in the UK who need care for musculoskeletal complaints but have to wait months to get an appointment with a General Practitioner (so they can then be referred to a Physio). 

The Solution: Direct access to services provided by a physical therapist 

The Result: Swift, effective care for people of all socioeconomic classes with musculoskeletal disorders leading to reduced work absenteeism, reduced direct costs, and increased patient satisfaction (per the published govt. report commented on in this article). Oh yea, also employment for the 1,800 physiotherapists who have graduate since 2005 and want to treat patients but who cannot find work. 

One quarter of all consults from General Practitioners in the UK are for patients with neck and back pain complaints alone. What are they able to offer these patients?   Hmmm, it appears the “You have Drugs, Surgery, or Us” option applies internationally…it certainly does in this case. 

The Department of Health is calling on the leaders of the NHS to allow direct access. The APTA and its membership has been doing the same for some time now. Excuse me legislators and key health care decision makers: This is not rocket science- what’s not to get? 

Round and round and round we go, when will this madness (Medical visit ------ Consult ----------PT) stop nobody knows. However, one thing we do know, and that is that it won’t stop until our patients have the option and ensuing benefits of real (ie. unfettered and reimbursed) Direct Access.

 

Rob

Blue Cross of Minnesota will no longer pay for Manual Therapy

Over the past week, private practice PT owners have been receiving this provider bulletin (P22-08) Download post71a_125818.pdf in their mailboxes. Briefly it states:

Massage and manual therapy exclusion
Effective January 1, 2009, Blue Cross and Blue Shield of Minnesota and Blue Plus will no longer reimburse providers for massage or manual therapy services. Massage or manual therapy will deny either as incidental (provider liability) or subscriber liability.

Massages that are provided as preparation for a chiropractic manipulation or other physical medicine therapies, are considered an integral part of the chiropractic manipulation or other therapy. As such, we will deny it as provider liability. If a massage is billed alone, then it will be denied as a subscriber contract exclusion.

Codes
97124 Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion).
97140 Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes.

Liability
Provider liable:
Massage and manual therapy (97124 and 97140) will be denied incidental (provider liable) to chiropractic manipulations or other physical medicine procedures billed on the same date of service. The denial will be upheld regardless of submission of the -59 modifier. Additionally, submission of the -GA modifier will not affect or change the denial.

I found out about this Monday night and quite honestly said, What the Hey!! and immediately fired off emails to MN APTA, APTA, EIM team, friends, co-workers, etc.  Others have done so as well.

As of this morning, a  unified effort is taking place.   The MN chapter of the APTA is trying to get some answers from BC of MN and determine when and with whom we can meet to discuss. At present, Blue Cross of MN is not being very helpful.  Nationally, the APTA is aware of the issue and waiting to help if the matter can't be resolved by the MN Chapter and PT providers in a timely manner. 

In Minnesota, lots of theories are circulating as to exactly why and what Blue Cross was trying to do here.  From a research perspective, the recent September JOSPT Neck Guidelines and articles like the one by Walker et al. that came out in Spine today make supporting the efficacy of manual therapy and it's use with exercise a slam dunk. 

Hopefully we will have some answers soon.  I will keep you posted.  Could your state be next?

JW Matheson DPT

Image taken from here - see free use policy

Do We Collectively Really Make a Difference?

If we really want change, really want to reduce variation in practice, really want evidence implemented as much as possible into practice, what are we willing to do as individuals?

Do you sit back and follow Twitter?  Do you have Google Alerts?  Do have a slew of RSS feeds?

When you read a blog that seems as though one of your fellow colleagues is reaching out, what do you do?

I read this today and it compelled me to rethink how we can collectively make a difference.  To make a difference will really take more effort than being concerned about ourselves.  Being in this "community" isn't going to create change.  To make a difference will take time and effort to personally reach out, plant a seed, and offer an evidence based perspective to colleagues who are self-reflecting and contemplating.  Gryphon is in need of knowing if what was shared is what being a physical therapist is all about... is it?

Selena 

Got Guidelines

The Agency for Healthcare Research and Quality (AHRQ) released its weekly updates yesterday and I was pleased to see an update on the American College of Occupational and Environmental Medicine (ACOEM) Guidelines for low back disorders. These Guidelines can be downloaded from this page at www.guideline.gov

Here are just some of their major recommendations:

1. In the absence of red flags, primary care and occupational physicians or other health care professionals can effectively manage low back problems conservatively.
2. At the first visit, the physician should assure the patient that low back pain (LBP) is normal, has an excellent prognosis and, in most cases, is not debilitating on a long-term basis. Patients with elevated fear avoidance beliefs may require additional instructions and interventions to be reassured of this prognosis. Theoretically, this reassurance has the potential to avoid increasing the probability of the patient developing chronic pain syndrome.
3. All patients should be encouraged to return to work as soon as possible as evidence suggests this leads to the best outcomes. This process may be facilitated with modified duty particularly if job demands exceed patient capabilities. Full-duty work is a reasonable option for patients with low physical job demands and the ability to control such demands (e.g., alternate their posture) as well as for those with less severe presentations.
4. Physicians should be aware that "abnormal" findings on x-rays, magnetic resonance images, and other diagnostic tests are so common they are normal by age 40. Bulging discs continue to increase after age 40, and by age 60 will be encountered in 80% of patients. This requires that a careful history and physical examination be conducted by a skilled physician in order to correlate historical, clinical, and imaging findings prior to assigning the finding on imaging to a patient's complaints. It is recommended that physicians unable to make those correlations, and thus properly educate patients about these complex issues, should defer ordering imaging studies to a qualified consultant in musculoskeletal disorders. Without proper education on prevalence, treatment, and prognosis, patients may become fixated on "fixing" their abnormality (which may in fact be a completely normal condition) and thus iatrogenically increase their risk of developing chronic pain.
5. Significant abnormalities in hip range-of-motion may increase the probability of back disorders.
6. There is evidence of efficacy for manipulation for treatment of non-specific LBP, particularly for those patients who test positive for the Clinical Prediction Rule.

I really like the www.guideline.gov site. It is at times hard to navigate with all the information so I have signed up for the weekly updates email blast here.

So how can we get PTs and Family MDs to read these Guidelines? My Top 5 (all dripping with sarcasm)

1. Post on the back of MRI reports
2. Hide inside the cover of Advance for PT
3. Enclose in a “guru” based Con Ed brochure
4. Make a Wii Interactive “Guidelines Game with Regis Phelbin asking you questions
5. Include with the side effects in the folded piece of paper that comes with your prescription narcotics and muscle relaxants

Seriously, how can we get the generic PT and the referring MD to utilize these Guidelines without waiting a decade for them to become accepted? How can we create change?

Physical Therapists Will be Branded!

I honestly feel like a kid at Christmas!

An update from the APTA:  "APTA contracted with CRT/tanaka last year to develop a brand for physical therapy that will educate consumers and professional audiences, create an emotional connection with consumers, raise the stature of the profession, and enhance relationships with external constituencies.  The concept, presented to the Board by public relations firm CRT/tanaka, captured the strengths of the profession.  The proposal reflects a deep understanding of our profession."

I suppose we'll learn more later this year, unless someone wants to share specifics!  I was one of those kids that always peeked at presents, so if anyone wants to unwrap a bit of this "proposal" I won't be offended.

By the way, I am definitely appreciating the timely communication on behalf of the APTA to members.

Selena